<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Name')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-name" class="form-control" name="row[name]" type="text" value="{$row.name|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Mobile')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-mobile" class="form-control" name="row[mobile]" type="text" value="{$row.mobile|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Q_1')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-q_1" class="form-control" name="row[q_1]" type="text" value="{$row.q_1|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Q_2')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-q_2" class="form-control" name="row[q_2]" type="text" value="{$row.q_2|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Q_3')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-q_3" class="form-control" name="row[q_3]" type="text" value="{$row.q_3|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Q_4')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-q_4" class="form-control" name="row[q_4]" type="text" value="{$row.q_4|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Q_5')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-q_5" class="form-control" name="row[q_5]" type="text" value="{$row.q_5|htmlentities}">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-primary btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
